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i <br /> Baf^rC 1680 RvucRS AVENUE _ VMLL�� 11--SPEC i ION CB CKLIS.1. <br /> 'V C SAN JOSE CALIFORNIA 45112 <br /> TECH SERVICES <br /> -.- (408)573-77771 FAx Client eh L/. g <br /> (448)573-0535 PHONE '�� - <br /> "�` ' `�� 5rfe Address )2 6 7 G,Pvlm tr.y /v Sfs c <br /> r <br /> T echnlctun r } -e 4 I <br /> N <br /> � f� t�r�� • � G <br /> Date <br /> t'013 <br /> I=Lid on box? 6=Casin0 secure, 12=Water-smnoing in wellbox7 1S�WelI�p funotsanat7 <br /> 2 Lid broken? 7 Casino cut level? 12a Standing above the kap of casino? 15 Can rip be pufled loose? <br /> 3 Lid bolts missino7 8 Debris in well>ox7 12b standing below tete mp of casrn37 17 Can caD seat out water,, <br /> 4 Lid bolts stripped? 9 Weilbox is too Far above arade7 12c Water hien with the top of casino 18 Padlock present? <br /> 5 Lid seal intact? 10 Wellbox is taa far beim1 grade' 13 Well map present? 19 Padlock Iuncbon2l7 <br /> 1 1 Weflbox is crushed/damaaed" 14 Wellcm- faund secure? <br /> 0 Check box if no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> Grw` hr� "qG� Nwt►^ Mer.r� aid eetw„e.+-f <br /> a� ry d <br /> Hole below all dettencles [flat could not be corrected and stili need to be corrected <br /> BTS Office asstans or Date Date <br /> Well I D Persisting Deficiency defers Correction to assioned corrected <br /> i <br /> I <br /> t <br />